Medicare updates payment details for flu vaccine, COVID-19 boosters

Just in time for influenza season, the Centers for Medicare & Medicaid Services has updated Medicare influenza vaccine payment allowances and effective dates for the 2022-2023 season. All allowances are for service from Aug. 1, 2022, through July 31, 2023.

As a reminder, vaccine administration is separately reportable from the vaccine product. To report administration to a Medicare patient, use code G0008 (administration of influenza virus vaccine).

CMS has more information, including resources on frequency, coverage, billing, and coding, on its Flu Shot webpage and in instructions for Medicare administrative contractors.

Administration of the influenza vaccine this season also presents an opportunity to co-administer updated bivalent COVID-19 boosters. In support of that effort, the American Medical Association (AMA) recently announced an editorial update to Current Procedural Terminology (CPT) that includes eight new codes for the bivalent COVID-19 vaccine booster doses from Moderna and Pfizer-BioNTech. The updated boosters are adapted for the BA.4 and BA.5 Omicron subvariants and the original coronavirus strain in a single dose.

Four of the eight CPT codes (91312, 91313, 0124A, and 0134A) can be used immediately, as the U.S. Food and Drug Administration (FDA) has authorized Moderna’s new booster in individuals age 18 and older and Pfizer-BioNTech’s new booster in individuals age 12 and older.

The remaining new codes (91314, 91315, 0144A, and 0154A) will be available if the FDA authorizes Moderna’s new booster in individuals 6 years through 11 years of age and Pfizer-BioNTech’s new booster in individuals 5 years through 11 years of age.

The new codes are detailed below.

Moderna bivalent booster — 18 years and older:

• 91313: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, bivalent, preservative free, 50 mcg/0.5 mL dosage, for intramuscular use,
• 0134A: Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, bivalent, preservative free, 50 mcg/0.5 mL dosage, booster dose.

Moderna bivalent booster — 6 years through 11 years:

• 91314: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, spike protein, bivalent, preservative free, 25 mcg/0.25 mL dosage, for intramuscular use,
  
• 0144A: Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRN-LNP, spike protein, bivalent, preservative free, 25 mcg/0.25 mL dosage, booster dose.

Pfizer-BioNTech bivalent booster — 12 years and older:

• 91312: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, bivalent spike protein, preservative free, 30 mcg/0.3 mL dosage, tris-sucrose formulation, for intramuscular use,
• 0124A: Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, bivalent spike protein, preservative free, 30 mcg/0.3 mL dosage, tris-sucrose formulation, booster dose.

Pfizer-BioNTech bivalent booster — 5 years through 11 years:

• 91315: Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, bivalent spike protein, preservative free, 10 mcg/0.2 mL dosage, diluent reconstituted, tris-sucrose formulation, for intramuscular use,
• 0154A: Immunization administration by intramuscular injection of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) (coronavirus disease [COVID-19]) vaccine, mRNA-LNP, bivalent spike protein, preservative free, 10 mcg/0.2 mL dosage, diluent reconstituted, tris-sucrose formulation, booster dose.

A vaccine code finder resource from the AMA can help clinicians and staff identify the appropriate CPT code combination for the type and dose of COVID-19 vaccine provided to each patient.

— Kent Moore, AAFP Senior Strategist for Physician Payment

Posted on September 14, 2022, by Kent Moore